In the Friday, September 12, 2014, issue of The Wall Street Journal, Dr. Mark Sklar wrote an Op-Ed piece entitled “Doctoring in the Age of Obamacare.” His message was depressingly similar to what so many physicians are saying: government-mandated changes in healthcare payment, delivery, and electronic medical requirements are reducing productivity and patient satisfaction and the quality of care.
What has gone wrong? Although Sklar documents some of the problems, and others appear in other commentaries about these requirements:
- Governments and insurance plans force doctors to use EMR’s, but without determining how to make their usage practical. When major companies attempted to implement enterprise software systems in the early 1990’s, most efforts failed because they did not understand how to move the organizations to practical and more efficient work processes.
These efforts tended to be led and implemented by IT departments with insufficient engagement with those who would be using the software. Major companies got it right the 2nd or 3rd time around and made change management work central to their enterprise transformation efforts. If healthcare is to avoid having a series of failed 1st time efforts, it needs to be mindful of the lessons learned from major companies:
- Healthcare providers need to be mindful of the need for clinicians to maintain patient rapport while they are recording data.
- EMR vendors require rigid, standardized data entry processes. Checklists should only include what is necessary, but the EMR systems should enable clinicians to supplement them and to make future use of what they supplement.
- EMRs only work effectively if all EMRs in every part of the healthcare system are linked in a comprehensive health record continually available to everyone. Clinicians cannot rely on us to remember everything that happened outside that clinician’s office. This problem is made worse by the number of different specialists patients with increasingly complex chronic diseases visit.
- The 2009 stimulus legislation stated that, by January 1, 2014, patients would receive direct electronic health information from providers. This legislation provided that providers’ ability to engage in electronic interaction with patients would be the foundation for an electronic health record’s “meaningful use” and would affect how much they were paid. The effective date of the “meaningful use“ regulations has been delayed.
- At Dossia, we believe strongly in a user-friendly, lifelong and comprehensive patient-controlled record to which all EMR’s provide data, not simply fragmented and separate access to each physician’s electronic health record. EMRs are not designed for easy patient understanding. They help clinicians efficiently create a record used to support clinical recall, a claims process and the ability of independent reviewers to evaluate care quality. They need significant translation for patient self-management.
- Health plan administrators have relatively comprehensive health records, since they receive claims from the physicians. In fact, their database is far easier to access for a comprehensive health record than it would be for each of us to try to build a comprehensive health record from the multiple clinicians we access. However, there are fundamental limitations of health plan member portals:
- When health plan administrators receive provider claims, they spend between 60-120 days “adjudicating” it. Accordingly, member portals are routinely 60-120 days out-of-date. To be most useful, health information needs to be usable by a patient and other clinicians when created.
- Self-insured employers select particular health plan administrators and replace them from time to time. Employers need to require administrators to transfer data into employee portals or into the next administrator’s record.
- Critical data accumulated for an individual comes from health risk assessments, biometric screenings, and other medical events that do not appear in a claims database. That data needs to be able to be integrated into a complete portal.
- Families most need an integrated health record, not a separate record for each family member. Health plan portals typically do not enable a family care leader to have single sign-on access to all family’s records. It becomes cumbersome for a mother, who usually fulfills this role, to manage family health through multiple electronic portals. Imagine that a family of five accesses an average of three physicians apiece. That would require the family care leader to access 15 separate portals, with 15 separate sign-offs. One sign-on for all the portals that accesses all clinicians serving all family members is what will maximize health and healthcare engagement.
- Individuals and families most need authoritative content and guidance based on timely and complete data about their health condition. Health plan and clinical portals only aggregate data. They depend on human beings to intervene and contact patients to guide them through the health management process.
We will reverse long term declining population health trend when every stakeholder managing a particular population’s health is equipped with the same data and is aligned to manage the health and well-being of populations continually, not just when someone enters the healthcare system.
Continuous health and healthcare management requires a seamless access among desktop, laptop, tablet, and smart phone tools. Additionally, we must receive communications triggered by medical diagnoses, demographic information, biometric data entries, ticklers based on times or dates, household moves, job changes, or life events.
Beyond these specific triggers, we need continuous help as we go about our daily routines. Our state of health, particularly our weight, our physical fitness, our emotional stability and well-being, and our social well-being result from hundreds of conscious and unconscious decisions every day, as well as many environmental influences of which we are not aware.
For example, Professor Brian Wansink of Cornell, one of the world’s leading food researchers, has found that the average American confronts 200 separate food consumption decisions every day. All of us need help navigating through this decision environment to emerge as healthy as possible.
The tools to do this must be available at all times to help us incorporate healthy behaviors into our daily routines, or to give us practical alternatives on changing them. Our healthcare providers have neither the time nor the skill to help us do this.
At the center of this entire effort must an individually controlled and highly-personalized health record that guides each of us to make the right decisions every day to maximize our health and well-being.